Environment International 119 (2018) 287–294

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Environment International
journal homepage: www.elsevier.com/locate/envint

Traffic noise, noise annoyance and psychotropic medication use T

a,⁎ a a a b
Enembe O. Okokon , Tarja Yli-Tuomi , Anu W. Turunen , Pekka Tiittanen , Jukka Juutilainen ,
Timo Lankia,c
a
Department of Health Protection, THL - National Institute for Health and Welfare, P.O. Box 95, FI-70701 Kuopio, Finland
b
Department of Environmental Sciences, University of Eastern Finland, Yliopistonranta 1, FI-70210 Kuopio, Finland
c
School of Medicine, University of Eastern Finland, Yliopistonranta 1, FI-70210 Kuopio, Finland

A R T I C LE I N FO A B S T R A C T

Handling Editor: Martí Nadal Background: Road-traffic noise can induce stress, which may contribute to mental health disorders. Mental
Keywords: health problems have not received much attention in noise research. People perceive noise differently, which
Noise annoyance may affect the extent to which noise contributes to poor mental health at the individual level. This paper aims to
Modelled noise exposure assess the relationships between outdoor traffic noise and noise annoyance and the use of psychotropic medi-
Sleep medication cation.
Anxiolytics Methods: We conducted a survey to assess noise annoyance and psychotropic medication among residents of the
Antidepressants Helsinki Capital Region of Finland. We also assessed the associations of annoyance and road-traffic noise with
Noise sensitivity
sleep disorders, anxiety and depression. Respondents were randomly sampled from the Finnish Population
registry, and data was collected using a self-administered questionnaire. Outdoor traffic noise was modelled
using the Nordic prediction model. Associations between annoyance and modelled façade-noise levels with
mental health outcome indicators were assessed using a binary logistic regression while controlling for socio-
economic, lifestyle and exposure-related factors.
Results: A total of 7321 respondents returned completed questionnaires. Among the study respondents, 15%, 7%
and 7% used sleep medication, anxiolytic and antidepressant medications, respectively, in the year preceding the
study. Noise annoyance was associated with anxiolytic drug use, OR = 1.41 (95% CI: 1.02–1.95), but not with
sedative or antidepressant use. There was suggestive association between modelled noise at levels higher than
60 dB and anxiolytic or antidepressant use. In respondents whose bedroom windows faced the street, modelled
noise was definitively associated with antidepressant use. Noise sensitivity did not modify the effect of noise but
was associated with an increased use of psychotropic medication.
Conclusion: We observed suggestive associations between high levels of road-traffic noise and psychotropic
medication use. Noise sensitivity was associated with psychotropic medication use.

1. Background residential dwelling (Easthope, 2004). Noise from a constant source

Effective urban planning aims to increase connectivity between
people and their routine daily destinations, with the consequence that
city dwellers often live closer to roads and motorised traffic. With
higher population density, denser road networks and higher volumes of
traffic, road traffic becomes an intrusive presence that city dwellers
contend with daily. Recent estimates indicate that > 120 million people
are exposed to road-traffic noise exceeding 55 dB Lden in the European
Union, and 90 million of these people reside in urban areas (EEA,
2014). Residential exposure is particularly important because people
spend more time at home than elsewhere and commonly attribute a
sense of control, predictability and safety to the familiar setting of their
such as road traffic may become an invasive fixture in this perceived
‘sanctuary’ leading to an exaggerated sense of helplessness and despair
in the more susceptible (Babisch, 2003; Westman and Walters, 1981).
Preceding research on non-auditory endpoints of noise exposure has
focused extensively on cardiovascular risks (Babisch, 2003; Bilenko
et al., 2015; Foraster et al., 2014; Floud et al., 2013; Gan et al., 2012;
Huang et al., 2013; Seidler et al., 2016; Floud et al., 2011). Fewer
studies have considered metabolic outcomes, specifically, diabetes
mellitus and obesity (Dzhambov and Dimitrova, 2016; Sørensen et al.,
2013; Oftedal et al., 2015). Noise annoyance is a negative psychological
reaction to noise that has also been broadly investigated (Dratva et al.,
2010; Ouis, 2001; Guski et al., 1999; Brown et al., 2015). It expresses

⁎
Corresponding author at: Department of Community Medicine, Faculty of Medicine, University of Calabar, P.M.B 1115, Calabar, Nigeria.
E-mail addresses: enembe.okokon@thl.fi (E.O. Okokon), tarja.yli-tuomi@thl.fi (T. Yli-Tuomi), anu.turunen@thl.fi (A.W. Turunen), pekka.tiittanen@thl.fi (P. Tiittanen),
jukka.juutilainen@uef.fi (J. Juutilainen), timo.lanki@thl.fi (T. Lanki).

https://doi.org/10.1016/j.envint.2018.06.034
Received 2 November 2017; Received in revised form 20 June 2018; Accepted 25 June 2018
Available online 06 July 2018
0160-4120/ © 2018 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
E.O. Okokon et al.
the sense of disturbance or helplessness due to noise (Guski et al.,
1999). There have been suggestions that annoyance, which is sustained
over significant periods, can act as an intermediary between noise ex-
posure and the emergence of disease (Hammersen et al., 2016;
Niemann and Maschke, 2004; Öhrström, 2004).
Sleep disturbance is a well-known consequence of noise, which is
more prevalent with night-time exposures. Sleep disturbance has been
demonstrated in both laboratory (Öhrström et al., 1990) and popula-
tion-based noise studies (Frei et al., 2014). Interventions, which have
led to reduced road-traffic noise at residential buildings, have also re-
sulted in reduced sleep disturbance (Öhrström et al., 1990; Amundsen
et al., 2013). Higher risks of insomnia, reduced sleep quality and non-
restorative sleep have been observed with night-time noises. (Frei et al.,
2014; Muzet, 2007; de Kluizenaar et al., 2009; Evandt et al., 2017;
Halonen et al., 2012) A meta-analysis of 28 datasets showed that road-
traffic noise posed a higher risk of sleep disturbance than rail-traffic
noise (Miedema and Vos, 2007). However, this study adjusted for only
age as a covariate. For optimal sleep value, the WHO recommends an
outside night-time noise limit of 40 dB Lnight,outside and an interim target
of 55 dB Lnight,outside (World Health Organization, 2009).
Noise sensitivity is an individual innate trait that increases the in-
dividual's susceptibility to irritation from noise (Basner et al., 2013;
Heinonen-Guzejev et al., 2012; Ryu and Jeon, 2011; van Kamp et al.,
2004). It is a consistent determinant of noise annoyance (Miedema and
Noise Sensitivity, 2003). Noise-sensitive persons are generally less tol-
erant of noise and are prone to rate noise as being louder than non-
sensitive persons would (Moreira and Bryan, 1972).
Studies that explore chronic neuropsychological sequelae of road-
traffic noise are scant. Although investigators have assessed the effects
of noise on cognitive function and behavioural symptoms in children
(Crombie et al., 2011; Dreger et al., 2015), fewer yet have explored the
mental health consequences of noise in adults. Although studies that
target adults have produced conflicting results, infrequently, residential
noise exposure has been associated with anxiety (Stansfeld et al., 1996;
Standing and Stace, 1980; Edsell, 1976). An early review acknowledged
that emotional and psychological deficits stemming from noise annoy-
ance can, in the long term, lead to help-seeking responses, including the
use of sleep medication and anxiolytic and anxiolytic drugs (Westman
and Walters, 1981). A few studies preceding this review had reported
increased mental-hospital admissions in association with aircraft noise
exposure (Abey-Wickrama et al., 1970; Meecham and Smith, 1977).
Existing studies on the mental health effects of road-traffic noise
have mostly used modelled (Brink, 2011; Orban et al., 2016; Fyhri and
Aasvang, 2010; Sygna et al., 2014) or measured (Öhrström, 2004;
Stansfeld et al., 1996; Öhrström and Björkman, 1983) noise to assess
exposure. However, it is generally acknowledged that individual noise
perception varies between persons, and perception by the same person
changes over time. Noise perception is not always determined by sound
pressure level, it also hinges upon the quality and context of the sound
stimulus, current activity and engagements of the recipient, individual
temperament, cognitive style, state of mind and health, level of control
over the sound stimulus, attitude toward sound source etc., which all
give meaning and interpretation to incipient sound (Westman and
Walters, 1981; Basner et al., 2013). Noise annoyance is an expression of
psychological strain due to noise. By estimating noise annoyance, in-
dividual differences in noise perception and the ensuing effects can be
considered. This study aims to determine how road-traffic noise affects
mental health indicators, namely: sedative, anxiolytic and anti-
depressant use. We also compare the effects of noise annoyance and
modelled noise on these indicators.
2. Methods
2.1. Study design and participants
The Helsinki Capital Region Environmental Health Survey was
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Environment International 119 (2018) 287–294
conducted in the Helsinki metropolitan area, which comprises Helsinki,
Espoo and Vantaa. The survey was carried out to evaluate perceived
exposures to specific environmental factors by residents and their views
of the possible health risks caused by the environment. The survey as-
sessed health risks associated with noise and air pollution and also the
health benefits that are derived from access to green areas.
Additionally, some medical history and data on confounders were col-
lected to facilitate epidemiological analysis. The survey questionnaire
had 93 questions and numerous subquestions. The survey was con-
ducted in two phases: first, in the city of Helsinki from the latter part of
May to August 2015, and, second, in the cities of Espoo and Vantaa
from June to August 2016. Eight-thousand Helsinki residents age
25 years and above were selected from the Population Registry of
Finland using simple random sampling in 2015. Similarly, 4000 re-
sidents of Espoo and 4000 residents of Vantaa were sampled in 2016,
yielding, in total, 16,000 residents. Potential respondents were con-
tacted by post and invited to fill a self-administered questionnaire,
which they could choose to complete electronically or on paper. This
sample consisted of 53% women and 47% men. A single reminder was
sent to non-respondents. The response rate was 47% in 2015 and 45%
in 2016.
2.2. Exposure
Noise annoyance was assessed using the questionnaire item, ‘Are
you usually disturbed or your concentration disturbed or annoyed by road-
traffic noise when you are at home, indoor and the windows are closed?’
Anchors to this question were: i) no annoyance; ii) slight annoyance; iii)
some annoyance; iv) severe annoyance; v) extremely annoyance. To
facilitate statistical analysis, respondents were then divided into two
groups: ‘none to mild annoyance’ (no annoyance and slight annoyance)
and ‘moderate to severe annoyance’ (some annoyance, severe annoy-
ance and extreme annoyance). Residential exposure to road-traffic
noise was estimated from façade noise maps, which were modelled by a
consulting company, Sito, for the Helsinki Capital Region (Oy, 2012).
Road-traffic noise was estimated in accordance with the EU Environ-
mental Noise Directive 2002/49/EC (EEC, 2002) using the Nordic
prediction method (TemaNord 1996:525) (Nielson et al., 1996) for
major highways and the main and collector streets within an area
(Nielson et al., 1996). Input variables for the noise model include ter-
rain characteristics, ground surface, buildings and noise barriers and
traffic flow, speed and proportion of heavy vehicles for the year 2011.
The 2011 estimates remain valid because land-use and traffic changes
in the latter years have been insufficient to significantly alter façade
noise levels (Supplement S1). The highest Lden on façade points within
20 m of residents' home address coordinates was used as the exposure
estimates. Lden is the A-weighted day-evening-night equivalent con-
tinuous sound level calculated over a 24-hour period. A 10 dB penalty
was added to the levels between 22.00 and 07.00 h, and a 5 dB penalty
was added to the levels between 19.00 and 22.00 h to reflect people's
extra sensitivity to noise during the night and the evening. Noise
modelling was based on 2011 data; thus, newer buildings—74 (6%) out
of 5931 sampled buildings—had missing façade noise values.
2.3. Outcome variables
The use of sleep medication, anxiolytics and antidepressants were
elicited in the survey as proxy measures for sleep disorders, anxiety
disorders and depression. We used the single question, ‘When did you
last take the following medication?’ Listed among the medications were
sleeping pills, tranquilizers and antidepressants. Against each medica-
tion, respondents were asked to select from the following options:
‘during the past week,’ ‘1–4 weeks ago,’ ‘1–12 months ago,’ ‘over a year ago’
and ‘never’. Respondents selecting the last two options were considered
free of the outcome. As usage of psychotropic medication in Finland is
entirely prescription-based, we consider this a reliable approach for
E.O. Okokon et al.
assessing our index outcomes.
2.4. Individual-level covariates
We decided on confounder models a priori: variables likely to be
associated with both the exposure and outcome based on published
literature or rational judgement were included as confounders.
Sociodemographic data included age, sex, marital status, employment
status and household income level (average yearly income before
taxes). Details on lifestyle factors, including alcohol consumption,
current smoking status, weekly frequency of leisure-time physical ac-
tivity and pet ownership, were obtained from respondents. Pet owner-
ship is considered to be a potential confounder: persons with dogs (and
to lesser extent cats) are probably more likely to choose residential
areas with more access to green space and less traffic. Such residential
settings would foster lower noise exposure. Pet ownership is also as-
sociated with our outcome indices because of the direct value of ame-
liorating mental stress, while dog ownership indirectly affects outcomes
by the motivation for increased physical exercise. On the other hand,
persons already living in areas that are prone to heavy traffic may avoid
pet ownership because of the paucity of green space. In this scenario,
pet ownership is dependent on exposure and, therefore, should not be
considered as a confounder. This reasoning was taken into account in a
sensitivity analysis.
Some variables, which were not included in the main confounder
models, were tested for effect modification. These were: sleep dis-
turbance from road-traffic noise, noise sensitivity and orientation of
bedroom windows (if windows faced streets or not). Noise sensitivity
was measured using 11 items from the Weinstein noise sensitivity scale
(Weinstein, 1978). Seven of these items were reverse scored, and an
aggregate score was derived for each respondent. The aggregate sen-
sitivity scores ranged from 11 to 55. Additional information on how
variables were evaluated and categorised is provided in supplement S2.
2.5. Statistical analysis
We used a binary logistic regression to assess associations between
noise annoyance or modelled noise and psychotropic medication use.
Each outcome variable was dichotomised from the original five re-
sponse categories. We implemented several statistical models to ex-
amine relationships that specify psychotropic medication use relative to
annoyance and modelled noise exposures. The first model was a crude
model in which noise annoyance and modelled noise were separately
examined as explanatory variables for sedative, anxiolytic or anti-
depressant use while controlling only for sex and age. In the main
model, we controlled for more covariates, including sex, age, marital
status, employment status, household income, alcohol intake, current
smoking status, level of physical activity and pet ownership. Because
almost all respondents lived in urban areas, there was no justification to
control for urbanity in statistical models.
Modelled noise is the objective noise measure and forms the basis
for stronger conclusions on relationships. It is only appropriate to use
modelled noise for further sensitivity testing of our statistical models.
Some sensitivity models included variables that were considered to
potentially intervene on the pathway from exposure to effect. These
were, therefore, not included in the main model to avoid over-
adjustment. These variables were as follows: noise annoyance, noise
sensitivity, sleep disturbance, bedroom window orientation, BMI and
presence of chronic disease. In addition, a sensitivity model was run
without pet ownership. These models were tested for robustness of
results. Noise sensitivity, sleep disturbance, bedroom window orienta-
tion were tested for significant multiplicative interactions using the
Wald chi-square test. Only variables that interacted with modelled
noise were used in stratified analysis, while others were adjusted for as
confounders.
For the purposes of statistical modelling, residential noise levels
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Environment International 119 (2018) 287–294
were categorised into 5 groups: Lden ≤ 45 dB, 45.1–50 dB, 50.1–55 dB,
55.1–60 dB and ≥60 dB; age was inputted into the model as a con-
tinuous variable. A thin-plate regression spline function was applied to
age because it did not relate in a linear fashion with (the log odds) of
any selected outcome (Miedema and Vos, 2007). Model smoothing was
done using the function in the mgcv library of the R software (Wood,
2011).
We conducted further sensitivity analyses by separating the highest
exposure category (> 60 dB) into two categories (60.1–65 dB
and > 65 dB), and we used this in the main model. Additionally, we
repeated the main model but replaced categorised modelled noise levels
with the original continuous form of the variable, and we included a
smooth term to assess the shape of the exposure-response function.
Different degrees of freedom were tested for smooth terms. We assessed
multicollinearity between covariates. Post-hoc diagnostics did not re-
veal whether any regressor data point exerted a high influence on
outcome estimates. Statistical analysis was done in the R computing
environment, version 3.3.3 (R Core Team, 2017). All analyses were
conducted on a 95% confidence level, and odds ratios were reported as
estimates of risk.
3. Results
Overall, 7321 valid records were obtained from study participants,
giving a response rate of about 50% for women and 41% for men. The
response rate according to the 5th, 25th, 50th, 75th and 95th age
percentiles were 29%, 41%, 56%, 68% and 81%, respectively. The
majority, 3749 (51%) (from a general population of 635,181), of re-
spondents lived in Helsinki, with 1785 (24%) (from a general popula-
tion of 274,583) and 1784 (24%) (from a general population of
219,341) of respondents residing in Espoo and Vantaa, respectively. In
total, 6558 (90%) respondents had data on both noise annoyance and
modelled noise for their residential addresses. Stratifying this by mu-
nicipality gives 3425 (52%) in Helsinki, 1608 (25%) in Espoo and 1525
(23%) in Vantaa. There were 5860 (80%) records with no missing ex-
posure or confounder data. Forty-three percent of the study participants
were males, and the mean age of participants was 55 years (Table 1).
About 58% of the respondents were employed at the time of the study.
Proportionally, the respondents who were moderately or severely an-
noyed by noise were 4% in the least exposed (≤45 dB) compared to
19% in the most exposed (> 60 dB) noise categories (Table 1). There
were fewer severely noise sensitive persons residing in places with the
highest noise exposure compared to that in less exposed neighbour-
hoods (Table 1). The proportion of participants taking either sleep
medication, anxiolytics or antidepressants was approximately 15%, 7%
and 7%, respectively. The proportion of respondents who took more
than one of these medications in any combination was < 2.5%.
The highest category of modelled noise was associated with both
anxiolytic use and antidepressant use in the crude model. Noise an-
noyance was also associated with anxiolytic use in the crude model, but
its association with sleep medication or antidepressant use was less
clear. In the main model, modelled noise suggested an association with
both anxiolytic use (with an exposure-response gradient) and anti-
depressant use. The main model also revealed that noise annoyance
increased the odds of anxiolytic use by about 41% and retained the
suggestive association with sleep medication use (Table 2).
In the sensitivity models, neither noise sensitivity nor sleep dis-
turbance interacted with modelled noise. There was borderline asso-
ciation between the highest noise exposure category and anxiolytic or
antidepressant use in the model, which included noise sensitivity
(Table 3). Adding either noise sensitivity or sleep disturbance to the
main model did not dramatically change the odds ratios for modelled
noise, but there was evidence of negative confounding by noise sensi-
tivity as controlling for noise sensitivity yielded increased odds ratios.
Noise sensitivity was associated with increased use of all psychotropic
medication. Modelled noise showed similar relationships with slightly
E.O. Okokon et al. Environment International 119 (2018) 287–294

Table 1
Descriptive statistics of study participants by road-traffic noise level.
Na % Road traffic noise, dB (Lden)

≤45 (Na = 880) 45.1–50 (N = 1267) 50.1–55 (N = 1346) 55.1–60 (N = 1136) > 60 (N = 1231)

nb % n % n % n % n %

Agec 5860 55.0 (15.4) 54.5 (15.6) 54.5 (15.9) 54.4 (16.5) 53.5 (16.6)
Sex 5860
Female 3363 57.4 518 58.9 745 58.8 716 53.2 683 60.1 701 56.9
Male 2497 42.6 362 41.1 522 41.2 630 46.8 453 39.9 530 43.1
Marital status 5860
Single 1026 17.5 132 15.0 223 17.6 212 15.8 208 18.3 251 20.4
Married/registered relationship/ 3822 65.2 593 67.4 846 66.8 908 67.5 722 63.6 753 61.2
cohabiting
Divorced/separated/widowed 1012 17.3 155 17.6 198 15.6 226 16.8 206 18.1 227 18.4
Employment status 5860
Employed 3389 57.8 529 60.1 734 57.9 784 58.2 642 56.5 700 56.9
Not employed 2471 42.2 351 39.9 533 42.1 562 41.8 494 43.5 531 43.1
Income 5860
< €30,001 1503 25.6 205 23.3 326 25.7 318 23.6 313 27.6 341 27.7
€30,001–€50,000 1477 25.2 214 24.3 310 24.5 336 25.0 297 26.1 320 26.0
50,001–€90,000 1808 30.9 259 29.4 386 30.5 433 32.2 337 29.7 393 31.9
≥€90,001 1072 18.3 202 23.0 245 19.3 259 19.2 189 16.6 177 14.4
Noise sensitivity 5860
Mild 1535 27.6 224 27.1 320 26.4 352 27.7 285 26.4 354 30.0
Moderate 2808 50.4 409 49.5 590 48.7 646 50.9 552 51.1 611 51.7
Severe 1225 22.0 193 23.4 302 24.9 271 21.4 243 22.5 216 18.3
Noise annoyance 5860
None to mild 5321 90.8 843 95.8 1196 94.4 1268 94.2 1021 89.9 993 80.7
Moderate to severe 539 9.2 37 4.2 71 5.6 78 5.8 115 10.1 238 19.3
Sleep disturbance from noise 5860
None 4593 79.1 748 86.1 1073 85.2 1107 83.0 864 76.9 801 65.5
Slight 817 14.1 102 11.7 135 10.7 166 12.4 176 15.7 238 19.5
Moderate to severe 400 6.9 19 2.2 52 4.1 61 4.6 84 7.5 184 15.0
Orientation of bedroom windows 5860
Facing yard 3783 65.4 586 67.3 863 68.7 910 68.7 753 67.1 671 55.4
Facing street 2003 34.6 285 32.7 393 31.3 415 31.3 369 32.9 541 44.6

a
N (capitalized n) denotes the number of respondents within each Lden category or the total in each category of covariates.
b
n (lower-case n) denotes the distribution of response categories for each covariate within strata of Lden.
c
Figures presented here represent mean (standard deviation).

Table 2
Odds ratios (OR) for associations of perceived and modelled road-traffic noise (Lden) with use of sleep medication, anxiolytics and antidepressants.
Medicated Crude ORa Adjusted ORb
n (%) (95% CI) (95% CI)

Sleep medication (n = 5713) Modelled noise ≤45 dB 119 (14.1) 1 1

45.1–50 dB 194 (15.7) 1.15 (0.89–1.47) 1.17 (0.87–1.45)
50.1–55 dB 182 (13.9) 1.00 (0.78–1.29) 0.99 (0.77–1.28)
55.1–60 dB 168 (15.1) 1.08 (0.80–1.33) 1.06 (0.81–1.37)
> 60 dB 174 (14.4) 1.03 (0.80–1.33) 0.97 (0.75–1.26)
Noise Slight or none 754 (14.5) 1 1
Annoyance Moderate to severe 83 (15.8) 1.20 (0.93–1.54) 1.17 (0.91–1.51)
Anxiolytics (n = 5687) Modelled noise ≤45 dB 48 (5.7) 1 1
45.1–50 dB 82 (6.7) 1.18 (0.81–1.70) 1.12 (0.77–1.63)
50.1–55 dB 82 (6.3) 1.11 (0.77–1.60) 1.09 (0.75–1.58)
55.1–60 dB 79 (7.2) 1.26 (0.87–1.82) 1.24 (0.85–1.82)
> 60 dB 101 (8.4) 1.48 (1.03–2.11) 1.34 (0.93–1.93)
Noise Slight or none 343 (6.6) 1 1
Annoyance Moderate to severe 49 (9.4) 1.49 (1.09–2.05) 1.41 (1.02–1.95)
Antidepressants (n = 5688) Modelled noise ≤45 dB 49 (5.8) 1 1
45.1–50 dB 86 (7.0) 1.23 (0.85–1.76) 1.20 (0.83–1.73)
50.1–55 dB 84 (6.4) 1.15 (0.80–1.65) 1.13 (0.78–1.64)
55.1–60 dB 66 (6.0) 1.04 (0.71–1.53) 1.04 (0.70–1.53)
> 60 dB 97 (8.1) 1.43 (1.00–2.04) 1.32 (0.91–1.90)
Noise Slight or none 339 (6.69) 1 1
Annoyance Moderate to severe 43 (8.2) 1.26 (0.91–1.76) 1.15 (0.82–1.63)

a
Crude model adjusted only for age and sex.
b
Adjusted for sex, age, marital status, employment status, household income, alcohol intake, current smoking status, level of physical activity and pet ownership.

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Table 3
Odds ratios (OR) of associations of modelled road-traffic noise (Lden) with use of sleep medication, anxiolytics and antidepressants.
Noise exposure Sleep medication use Anxiolytic use Antidepressant use

OR 95% CI OR 95% CI OR 95% CI

a
Sensitivity model n = 5453 n = 5438 n = 5440
Modelled noise exposure
≤45 dB 1 1 1
45.1–50 dB 1.14 0.87–1.48 1.17 0.79–1.73 1.23 0.83–1.81
50.1–55 dB 1.05 0.80–1.37 1.13 0.76–1.67 1.19 0.81–1.76
55.1–60 dB 1.13 0.86–1.48 1.22 0.82–1.81 1.05 0.70–1.57
> 60 dB 1.04 0.79–1.37 1.46 0.99–2.13 1.42 0.97–2.08

Noise sensitivity
Mild 1 1 1
Moderate 1.37 1.12–1.69 1.34 1.01–1.77 1.40 1.04–1.87
Severe 2.71 2.16–3.39 2.22 1.63–3.04 2.11 1.53–2.92
Sensitivity modelb n = 5666 n = 5640 n = 5642
Modelled noise exposure
≤45 dB 1 1 1
45.1–50 dB 1.14 0.88–1.47 1.14 0.77–1.66 1.23 0.85–1.80
50.1–55 dB 1.01 0.78–1.31 1.09 0.75–1.60 1.17 0.80–1.72
55.1–60 dB 1.04 0.80–1.36 1.18 0.80–1.75 1.00 0.67–1.49
> 60 dB 0.93 0.71–1.21 1.32 0.90–1.92 1.32 0.91–1.93

Sleep disturbance
None 1 1 1
Slight 1.00 0.80–1.26 0.90 0.65–1.24 0.82 0.59–1.14
Moderate to severe 1.75 1.33–2.31 1.50 1.03–2.17 1.25 0.85–1.83

a
Adjusted for sex, age, marital status, employment status, household income, alcohol intake, current smoking status, level of physical activity, pet ownership and
noise sensitivity.
b
Adjusted for sex, age, marital status, employment status, household income, alcohol intake, current smoking status, level of physical activity, pet ownership and
sleep disturbance.

lower odds ratios in the sensitivity model that included sleep dis-
turbance. Sleep disturbances showed a stronger association with sleep
medication than it did with anxiolytic use. Statistical relationships re-
mained unchanged when either BMI or the presence of chronic illness
was added to the main model or when the six-category substitute of the
modelled noise variable was used in the analysis (results not shown).
Removal of pet ownership from the main model yielded minimal
changes to model estimates (Table S6). Similarly, the addition of noise
annoyance to the model without pet ownership gave no meaningful
change in the estimates for modelled noise (Table S6).
The spline plots showed that modelled continuous noise seemed to
have a linear relationship with psychotropic medication use (Fig. S3).
Exploring this relationship in a linear model showed that for a 5 dB
increase in noise, corresponding odds ratios were 0.99 (95% CI,
0.95–1.04), 1.04 (95% CI, 0.98–1.11) and 1.03 (95% CI, 0.97–1.10) for
taking sleep medication, anxiolytics and antidepressants, respectively.
Only the orientation of bedroom windows interacted with noise to
increase the odds of using antidepressants (Χ2 = 10.5, df = 4,
p = 0.032) (Table S5). Among the respondents whose bedroom win-
dows faced the street, modelled noise was strongly associated with
increased antidepressant use, showing about 200% higher odds in the
highest exposure category (Table S7).
4. Discussion
Our study found that modelled noise showed a suggestive associa-
tion with anxiolytic and antidepressant use, but not with sleep medi-
cation. Noise annoyance was associated with increased drug use for
anxiety and was less clearly associated with sleep medication use.
Modelled noise was significantly associated with increased odds of
antidepressant use in respondents whose bedroom windows faced the
street. There was no association between road-traffic noise exposure
and sleep medication use. Noise sensitivity was not an effect modifier,
but was associated with all psychotropic medication use.
4.1. Road-traffic noise and anxiolytic use
Noise annoyance was significantly associated with increased an-
xiolytic medication. Additionally, the highest category of modelled
noise showed a suggestive association with anxiolytic use in the main
model and the sensitivity model, which included noise sensitivity. Early
experimental studies highlighted the effects of noise on state anxiety
(Standing and Stace, 1980; Edsell, 1976). These studies showed that
noise exposure accentuated state (temporary) anxiety score but showed
no effect on trait (chronic) anxiety (Standing et al., 1990). Later studies
found a positive association between night-time road traffic noise and
either an increased anxiety score (Stansfeld et al., 1996) or a higher
procurement of anxiolytic medication by privileged people (Bocquier
et al., 2014). The latter finding was not replicated in other study po-
pulations (Floud et al., 2013; Orban et al., 2016).
Anxiety is characterised by worry. In severe cases, it often manifests
as somatic symptoms and can limit the capacity for normal daily
function (Stein and Sareen, 2015). Anxiety can be transient and con-
nected to specific life events or experiences, in which case it is cate-
gorised as state anxiety, or it may be chronic and excessive, as occurs in
trait anxiety. Treatment may be initiated for state anxiety where an
offending stimulus, such as noise, persists or when state anxiety is as-
sociated with other medical conditions. Noise-stress response occurs via
the endocrine activation of the hypothalamo-pituitary-adrenocortical
axis, which causes the release of cortisol, and autonomic activation of
the sympathetic nervous system. Stress, which is so induced, is thought
to create a feedback loop to the amygdala, which upregulates the cor-
ticotrophin-releasing factor and its receptors, leading to the manifes-
tation of anxiety symptoms (Eraslan et al., 2015; Spreng, 2000).
4.2. Road-traffic noise and sleep medication
We did not observe any clear association between road-traffic noise
and uptake of sleep medication. An earlier study in Finland supports
this observation (Halonen et al., 2012). Findings elsewhere also show

291
E.O. Okokon et al.
that although outside night-time noise was associated with poor sleep
quality, it was not associated with sleep medication (de Kluizenaar
et al., 2009; Evandt et al., 2017). Insulation against road-traffic noise
provided by double- or triple-glazed windows, which are primarily
designed to retain indoor heat during winter, likely explains this
finding. A report from Finland suggests that in Nordic countries, air-
borne sound insulation of building facade typically varies between
30 dB to 50 dB (Saarinen, 2002). This report has been supported by
independent findings from Denmark and Norway, where similar
window specifications have led to considerable indoor attenuation of
façade noise levels (Öhrström and Björkman, 1983; Bendtsen, 1999).
4.3. Road-traffic noise and antidepressants
Modelled noise showed a weak association with antidepressant use
in the main model, but was more clearly associated with an increased
use of antidepressants in respondents whose bedroom windows were
oriented toward the street. However, since stratification did not yield
any effect with anxiolytic use, this finding should be viewed with
caution. Although some authors have found a positive association be-
tween road-traffic noise and indicators of depression (Orban et al.,
2016; Seidler et al., 2017; Yoshida et al., 1997), this has not always
been the case (Stansfeld et al., 1996). Mixed findings are reported in
studies that measured mental health outcomes differently, for example,
use of an inventory that indistinctly evaluates anxiety and depression
(Hammersen et al., 2016; Sygna et al., 2014) or use of an audit in-
strument that collectively assesses anxiolytic and antidepressant use
(Watkins et al., 2009; Halonen et al., 2014). Unavoidably, these
methods combine anxiety and depression as a singular outcome, and
their results do not directly compare with the present study. Ad-
mittedly, the symptoms of depression overlap considerably with that of
anxiety. Differences in study findings can result from nuanced varia-
tions in the way exposures and outcomes are conceptualised and esti-
mated. Inconsistencies can also arise from inherent differences in the
populations studied, predominant noise levels, building types and in-
sulation in study settings.
4.4. Noise sensitivity
Noise sensitivity was expected to modify the effect of noise ex-
posure, but paradoxically, no modification was detected in this study.
Rather, we found an independent association with psychotropic medi-
cation use. This observation is in line with other studies (Stansfeld
et al., 1985; Stansfeld et al., 2000). Possible explanations for this could
be that: First, noise-sensitive persons may be more sensitive to other
stressors which mask the effect of noise. Noise sensitive persons are
generally more conscious of their environments and are more suscep-
tible to stress and worry (Miedema and Vos, 2003). Relationships be-
tween noise sensitivity and anxiety have been acknowledged (Park
et al., 2017; Iwata, 1984) with the implication that noise sensitivity
may positively co-vary with anxiety without the influence of a noise
source (Persson et al., 2007). Second, noise-sensitive people may se-
lectively reside in quieter parts of town thereby minimising the influ-
ence of higher exposure. There is slight evidence that severely noise-
sensitive respondents in our study sample tended to live in less noisy
areas. We also observed that about 18% of the residents in areas with
noise > 60 dB were severely noise sensitive. These people may have
chosen to stay in those areas because they were healthy. The inclusion
of noise sensitivity increased effect estimates in the highest noise ex-
posure category in the sensitivity model relative to the main mod-
el—pointing to a negative confounding effect.
4.5. Noise annoyance versus modelled noise
Noise annoyance was more clearly associated with anxiolytic use
than with modelled noise, but weakly associated with sleep medication.
292
Environment International 119 (2018) 287–294
The highest category of modelled noise gave higher odds for anti-
depressant use in than noise annoyance. Comparing the behaviours of
both exposure measures in the crude and main models, no variable was
consistently more associated with the outcome. Annoyance is de-
termined by noise levels and more consistently by noise sensitivity.
Noise annoyance more directly correlates with indoor noise, while
modelled façade noise represents outdoor exposure. Previously, few
studies have compared the relationships of noise annoyance and mod-
elled noise to health outcomes even though combining both subjective
and objective exposure has been recommended in epidemiologic studies
(Babisch, 2005). Using noise annoyance as a proxy for exposure, some
investigators were able to demonstrate relationships with select out-
comes that are more often examined in association with objectively
measured noise (Hammersen et al., 2016; Dreger et al., 2015; Babisch,
1998; Lercher et al., 1993; Meijer et al., 1985; Pitchika et al., 2017). As
aforementioned, noise annoyance is influenced by individual noise
sensitivity, therefore associations between noise annoyance and out-
comes of interest may more closely reflect individual sensitivity to noise
rather than the absolute effect of sound energy. Noise annoyance may
be the only option in large-scale population studies that incorporate
human participants living in areas that are not represented on noise
maps (Dzhambov and Dimitrova, 2014). Objectively measured noise is,
however, preferred in epidemiologic studies because it is more valid.
Modelled noise can facilitate a meaningful comparison between popu-
lations. It provides a better yardstick for assessing the immediate effects
of interventions that aim to reduce noise or infrastructural changes that
increase exposure levels. This is because strict values can be assigned to
expected reductions in modelled noise due to interventions, while an-
noyance levels can vary on the same noise levels and may exaggerate
the actual noise reduction (Öhrström, 2004; Amundsen et al., 2013).
Annoyance, on the other hand, will provide an indication of the long-
term consequence of interventions and the satisfaction of local popu-
lations with interventions (Amundsen et al., 2013).
4.6. Strengths and weaknesses
Our study strength includes a relatively large study population and
the use of two indicators of noise exposure: noise annoyance and
modelled noise, the latter being the more objective measure of ex-
posure. Noise annoyance is not only an indicator of noise exposure but
also represents an effect. It can be argued that annoyance has the ad-
vantage of representing indoor exposure more closely, and it takes into
account not just noise levels, but also other characteristics of noise. On
the other hand, the cross-sectional design of the study does not permit
one to infer whether annoyance precedes medication use or vice versa.
Asking questions about medication is a relatively straightforward
method. Adults typically know what conditions they are receiving
medication for, even when they may not know the pharmacological
classification of individual medicines. In Finland, sleeping pills, an-
xiolytics and antidepressants can only be obtained by prescription.
Therefore, in this study, psychotropic medication use as an outcome
represents a diagnosed condition requiring treatment. We administered
a general environmental health questionnaire; medication use was
asked in a section unrelated to any exposures. Therefore, respondents
were less likely to bias their responses based on noise exposure.
The response rate in the study was relatively high by today's stan-
dards, but it may appear as a weakness because of the possibility of self-
selection. Persons who are more worried about environmental ex-
posures and consequently more annoyed by noise, for example, would
probably be more likely to participate in the study. This may have in-
creased our chances of finding an effect, but should not have created
spurious associations.
Noise annoyance was not included in our main model because it
may likely mediate the effects of noise exposure on medication use.
However, in our sensitivity analyses, changes in effect estimates for
modelled noise and annoyance were negligible when both variables
E.O. Okokon et al.
were mutually adjusted for. We did not conduct an in-depth mediation
analysis, but the results suggest that annoyance and modelled noise
exert independent effects in this study population.
We were not able to control for road-traffic-related air pollution in
this study even though it is a co-exposure with road-traffic-related
noise. Evidence of an association between air pollution and physician-
diagnosed or self-reported symptoms of depression has been demon-
strated in several longitudinal and cross-sectional studies (Kim et al.,
2016; Kioumourtzoglou et al., 2017; Lim et al., 2012; Pun et al., 2017;
Vert et al., 2017). An association has also been shown between air
pollution and anxiety (Power et al., 2015). Notably, none of these
studies adjusted for the effect of noise. Zijlema and colleagues, in their
multinational study, mutually adjusted for air pollution and noise while
investigating depressive symptom score as an endpoint. Findings from
this study were heterogeneous, and participants from Finland were
among those in whom no association between air pollution and
symptoms of depression was apparent (Zijlema et al., 2016).
5. Conclusion
In conclusion, we found some evidence of an association between
either noise annoyance or modelled noise exceeding 60 dB and psy-
chotropic medication use. There were no consistent differences between
annoyance and outdoor noise in the strengths of association. Noise
annoyance may find use in study areas where modelling of noise is not
realistic. Noise sensitivity was associated with psychotropic medication
use, but it did not modify the effect of noise. The fact that some evi-
dence of noise effect was observed despite the effective sound insula-
tion in buildings located in this northern study area suggests that the
mental health effects of noise may be significant. This finding should
stimulate similar studies in regions with different climatic conditions.
Conflicts of interest
The authors declare no conflicts of interests.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.envint.2018.06.034.
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